Shrinking the Digital Divide

With etherapy, you get no guarantee that a cyber therapist is licensed Ñ or even legitimate. Cyberspace operates ahead of its time. The World Wide Web transcends geographic borders and governing boundaries; ehealth waits for the laws to catch up. Lucy Van Pelt, self-proclaimed psychiatrist in the Peanuts comic strip, set up a booth and hung up a sign: "The Doctor Is In. Psychiatric Help 5 cents." In telemedicine today, the doctor is in -- and online. The medical profession has been developing telehealth technology for more than 35 years; integration of classic telemedicine (using telecommunications to provide health information and services) and telehealth technologies was the next step. Following the 1999 White House Conference on Mental Health, hundreds of ecounselors and etherapists rushed to set up offices on the Internet. Some mental health professionals, like psychologist Dr. Erin Smith of Madison, Ala., argue that most counselors who set up online practices are virtual proprietors of etherapy lemonade stands.

In 1999, Dr. Jeri Fink wrote Computers and Cyberspace in the Clinical Practice of Psychotherapy, the first book on the subject. In it, she coined the term "psychotechnology." Fink is a family therapist in Merrick, N.Y., whose articles have appeared in numerous publications, including The New York Times and Redbook. Fink says that online therapy has evolved to offer a faster, more direct means of communication that is not affected by time, space, or location.

Therapy is usually defined as treatment of a mental-health problem following a clinical diagnosis. Many online providers call themselves "counselors" rather than "therapists," choosing a conservative title that promises help as opposed to clinical healing. During an online session, psychiatric service can consist of a single email reply to a patient's question, or continued chat-room dialogue as part of ongoing etherapy. Skeptical health-care professionals contend that text-based techniques aren't therapeutically viable.

Fink, however, believes online therapy can be effective -- in combination with the more traditional methods. She uses it as a complement to face-to-face sessions. "As long as I know my patient, understand the issues and history, then online therapy can work very well," she says. "I visualize future sessions where patient and therapist communicate via video broadcasts, where nonverbal and environmental cues will serve as diagnostic tools. Perhaps one day a session might consist of holograms in an office, simulating the give-and-take of therapeutic sessions."

Smith and Tamara Pellant, a licensed counselor with Pellant Psychology Services in Madison, Ala., add that not only are critical markers lost in an "impersonal environment," but so is the patient comfort derived from visual assurance and consistency. People often are dealing with chaotic or confusing situations, thus placing familiarity and reliability at the heart of effective therapy. Both Smith and Pellant do use email -- but only as an auxiliary tool when a client is unable to attend a session. Smith adds that email is still only an option "after a solid clinician/client rapport has been established." Many traditional therapists and academic institutions remain unconvinced about the online modality in theory. In practice, additional issues like credentials and confidentiality intensify their concerns.

With etherapy, you get no guarantee that a cyber therapist is licensed -- or even legitimate. Cyberspace operates ahead of its time. The World Wide Web transcends geographic borders and governing boundaries. Like ecommerce, ehealth waits for the laws to catch up. Even when restrictions apply and codes exist, they are hard to impose and enforce. There are counseling Web sites that provide bios, licenses, and limitations up front -- but there still is no face behind the desk and no diploma on the wall to verify.

Be cautious of what's packaged and advertised to you online, says Dr. Larry Rosen, a professor and research consultant at California State University, Dominguez Hills. Author of TechnoStress: Coping With Technology @ Home, @Work, @Play and The Mental Health Technology Bible, he warns of serious and potentially dangerous misrepresentation. One online therapist "admitted that he had lost his license to practice and went on to tell everyone why. Yet he still had a clinic and presumably some patients."

A walled office can be compromised by an outside intruder or a snoopy staffer -- but there are endless possibilities for compromise on the Internet. Critics say that no online therapist can promise confidentiality because of the limitations of Internet security. Email from a private account with an Internet Service Provider is legally protected but not email sent from private offices, where the network owner can monitor activity. Not all Web browsers are designed to ensure that messages will be delivered unread. Many routers store email in plain text and are susceptible to eavesdropping. Encryption methods are often beyond the experience of most email users. A private message always carries the risk of being intercepted and read.

Elizabeth Zelvin, a New York clinical social worker who is licensed, declares that skilled psychotherapy and meaningful change can and do take place in the online clinical environment. Zelvin has worked as a psychotherapist for 20 years, five of them online at LZcybershrink.com. She is the author of three books and has published many online therapy articles, the most recent in the March issue of the British journal Therapy Today. She has found that those who disparage online treatment are mainly clinicians who lack experience or training to work with clients in cyberspace. "The powerful expression of spoken English has its counterpart in written English, the language of Shakespeare, in direct contradiction to the perceived shallowness of Netspeak," she says.

Far from robbing the etherapy session of depth and emotion, Zelvin says that text-based communication uses different techniques for expressing feelings and interactions, and that Internet language -- complete with a range of words, symbols, and silences -- conveys layers of meaning and mood. Assisted by a professional fluent in and comfortable with the same medium as the client lies the "color and depth" online that so many office-only therapists charge is absent.

Zelvin hypothesizes that adherence to traditional therapy is grounded partly in the authority conveyed by what patients find: the big leather chair, the array of diplomas and even the analytic couch. She stresses that a virtual environment is more egalitarian, promoting give-and-take. It is an environment that holds both counselor and client accountable in an unprecedented way. Zelvin's Web site supports her online practice in ways designed to "welcome, soothe, and reassure." She describes her home page as what psychologists call a "transitional object," what most of us know as a "blankie," like the one Linus, Lucy's Peanuts brother, clutches for the powerful sense of security it holds for him. Zelvin emphasizes that when she is not "in," her site is still available to give clients therapeutic support any time of the day or night.

A skilled therapy-led, text-based session in a chat room strikes an emotional parallel to an office session, according to Zelvin, who adds that the process provides unexpected openings for self-discovery. It is a blending of autonomy and anonymity that helps clients reluctant or unable to reveal themselves f2f, the etherapy contraction for face-to-face.

"Email gives the time and the safety to get to know their particular truth as they share it with a therapist." Zelvin says. "Rereading a therapist's email or a transcript of the chat session reinforces constructive thinking and behavior."

It's no surprise that Zelvin, and many others like her, see a distinction between pathology and healing. Beyond therapeutic information, Zelvin's Web site offers poetry and music. Her logo, like her approach to therapy, is animated "without trivializing" the work involved: A turtle proclaiming, "It's a process!" walks through a field of flowers. The image typifies her philosophy that responsible online therapy, based on clinical knowledge and practical application, may be a good solution "for real people with real problems."

Dr. Rosen concedes that there are etherapy benefits for those who can't or won't seek traditional therapy. Agoraphobics, who have an irrational fear of public places, or people who lack transportation or access benefit from counseling that is as close as their computer. As with Fink, Rosen believes a worthwhile balance is possible if video teleconferencing and preferably at least one in-person meeting is part of treatment. "A face-to-face meeting at the beginning and then every once in a while is critical," Rosen says. He also worries that tactile prompts might be hidden in email text and symbolic pictures.

For Rosen, the ultimate use of computer technology for therapy right now is computer-simulated environment. He says, "Afraid of flying? Try a virtual-reality airline flight. Sit in a chair and don a helmet and you feel like you are in an airplane. If you are scared during ascent, the computer enables you to experience countless virtual take-offs. If you are scared of spiders, elevators or thunderstorms, there are virtual-reality machines ready to help you work through your fear. Although virtual-reality therapy is relatively new, research is beginning to show significant benefits."

The medical health profession has been developing telehealth technology and delivering telehealth information for more than three decades. For the telemedicine savvy like Fink, telepsychiatry was just another expected ehealth milestone. Though numbers vary, estimates are that in 2005, some 80 million people searched online for health information, nearly half of them looking for information about mental health. There may be more than 300 online counselors. Dollar projections vary, too, but reports suggest that the total online health and personal-care market could reach as much as $4 billion in 2006.

Some experts say Web-based therapy is the wave and the way of the future. Every day a growing number of people depend on the Web for advice and emotional support. Some look to the Internet for convenience, others for anonymity. High costs and low company co-pays, send some people shopping for bargain fees online. Aside from the issues of legality and legitimacy, several questions remain. Can an online mental-health practitioner can get a true sense of person's real-life situation and then adequately render service? Should the mental health community look at the numbers of people who seek counseling online and work to find ways to improve it instead of getting caught up in an emotional debate over its nuances? Should practitioners concentrate on all innovative therapies in the hope of meeting the mental-health needs of the next generation?

A local professor, who recently sought online counseling and had a positive experience, describes it this way: You moped away your week at the lake, you haven't showered in days. If you sat with a therapist, you'd worry that you looked bad and sounded worse. Or maybe it's not a good day outside for crutches, a walker or a wheelchair. Or your big meeting starts in an hour and you feel panic rising up in your chest. Or your glorious romance of three years just disintegrated. Or lots of little things have built up, and you feel like you're about to implode. You know there's no danger of you doing something egregious, but your problems are still very real. You feel safe there at your computer. That's when the right therapy for you might be waiting online.